Comprehensive CCM Tracking:

Monitors the overall management of patients with chronic conditions, displaying metrics such as total number of patients enrolled, average risk scores, and the effectiveness of ongoing interventions.

CCM Outreach and Engagement:

Provides insights into outreach efforts for chronic care patients, including enrollment and completion rates of care plans, which are crucial for maintaining continuous care and preventing exacerbations.

Performance Metrics:

Showcases VBC metrics including enrollment, readmission, and discharge rates to help monitor and boost performance under value-based contracts.

Claims and Revenue Analysis:

Presents claims by condition, provider, and program, offering valuable insights into the financial aspects of VBC and the effectiveness of different care strategies.

Seamless Data Sharing:

Facilitates the secure exchange of health information with other systems via HIE, enhancing the continuity of care across different healthcare settings.

Real-Time Access to Patient Data:

Provides healthcare professionals with immediate access to comprehensive patient records from across the network, supporting informed decision-making and personalized care strategies.

Patient Analysis:

Offers a breakdown of demographics by provider and coverage type, including Medicare, Medicaid, and commercial, which is crucial for targeted interventions in VBC.

Risk Score Analysis:

Segments risk scores by gender and age, helping to rank patients in order to tailor preventive and ongoing care effectively.

Focuses on metrics that pertain to patient discharges, highlighting engagement in transition-of-care processes and the scheduling of cardiology-related follow-ups.​​​

​6. Goals of Care Visits

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Ensures that all patients have established care goals, supporting personalized care planning and adherence to treatment protocols.